this presentation includes in detail description of complications post surgical phase of periodontal surgey

1. z
POST OPERATIVE
COMPLICATIONS OF
PERIODONTAL
SURGERY
GUIDED BY:- DR.SHWETA BALI
PRESENTED BY :- DR.NIVEDITHA REDDY

2. z
 A complication can be defined as a secondary
disease or condition developing in the course of a
primary disease or condition

3. z
General complications arising after
periodontal surgery
Bleeding
Swelling
Postoperative pain
Root Hypersensitive
Increased tooth mobility
Delayed wound healing
Trismus
Postoperative bacteraemia
Taste changes
Bruising

4. z
Complications arising due to the
surgical procedure employed
Local anaesthesia related
Flap related
Graft related
GTR related
Suture related
Periodontal pack related

5. z
Bleeding
 Though some amount of bleeding is considered normal post
operatively within 24 hours but patient should be examined for
the causative factors.
 Most common causative factors are infection, intrinsic trauma,
presence of foreign bodies, dislodgement of clot ,
displacement of periodontal pack and negative pressure
created by tongue.
 The most expected site to bleed is posterior maxilla
 Bleeding in a surgical patient can be classified as following:
 Primary bleeding
 Reactive bleeding
 Secondary bleeding

6. z
 Primary bleeding –this bleeding occurs during the
intra-operative period. This is mostly resolved
during the surgery, but if any major haemorrhages
are recorded, then the patient is monitored closely
post-operatively.
 Reactive bleeding – occurs within 24 hours of
surgery. Mostly it occurs when a ligature slips.
 Secondary bleeding – occurs 7-10 days post-
surgery. Secondary bleeding is often due to erosion
of a vessel from a spreading infection due to
contaminated wound.

7. z
 Management:-
 Anatomical Considerations
 Greater Palatine Artery: beware with a shallow palatal
vault
 Nasal Palatine Artery: usually not a problem
 Pterygoid Plexus of Veins: PSA injections
 Mental Vessels
 Inferior Alveolar and Lingual Artery (and branches):
rare but potentially catastrophic

8. z
 Mild bleeding - pressure pack for 15- 20 minutes. Still if
bleeding is persistent - haemostatic agents like surgicel,
gelfoam, microfibrillar collagen (Avitene) .
 Arterial bleeding - then ligating the vessel. [Hofschneider et al.
also noted that the sublingual and submental arteries may
traverse anteriorly very close to the lingual cortical plate, and
branches of these arteries may enter accessory foramina
along the lingual cortex] .
 Patients with heart or arterial diseases are more likely to
present postoperative bleeding because of the anticoagulation
therapy they are receiving.
 Haemophilia patients should always be treated in hospital
environment and a haematologist should always be consulted
in case of a need to administrate replacement factors.

9. z
 Goodacre et al. 2003 indicated that postoperatively
approximately 24% of all dental implant sites
manifest an ecchymosis. The location of an
ecchymosis can be influenced by gravity. It may be
noticeable only at the site of injury, or it may extend
to the inferior border of the mandible or onto the
chest. It reflects that the bleeding under the flap and
blood transcended along the fascial planes.
Ecchymosis extending to the pectoralis muscles
after removal of a maxillary bone cyst.

10. z Swelling
 Swelling is considered as the body’s normal
reaction to surgery and repair process
 Reach - maximum within 2-3 days post-
operatively.
 According to Akadiri et al. gender, weight and
body surface affect postoperative swelling.
 Swelling after an injury or surgery is to
increased blood supply to the affected body
part - extra nutrients to promote healing.

11. z
 Elha et al. reported that administration of 10 mg
dexamethasone IM, 1 h before surgery and 10-18 h later
together with antibiotic therapy (400 mg oral metronidazole,
administered pre-and post-surgically), significantly reduces
swelling when compared to only postoperative treatment,
without corticosteroids
 Chappi et al. has concluded that methylprednisolone affords
better pain relief while serratiopeptidase exerts better anti-
inflammatory and anti-swelling effects in the postoperative
period. Serratiopeptidase (Serratia E-15 protease also known
as serral-ysin/serratia-protease/serrapeptase) is a proteolytic
enzyme that has been used for reducing inflammation. It is
available as enteric coated tablets given in the dosage of
2.5mg -10mg

12. z
 studies postulated that good results were also
obtained with 32 mg methylprednisolone and 400
mg ibuprofen administered 12 h before and 12 h
after surgery respectively .

13. z
Post Operative Pain
 Postoperative pain experienced within the first 3 days after
surgery is considered normal and should progressively
diminish throughout the healing phase.
 Extensive and long surgical procedures
 poor tissue handling (including incising with a dull instrument,
tissue trauma, and poor local anaesthesia)
 poor infection control (which increases the risk of
postoperative infection)
 poor knowledge of surgical anatomy (which increases the risk
of complications, such as nerve injury and oedema)
 Patients whose healing process might be delayed –
Immunocompromised, Uncontroable Diabetes, On
Bisphophonates, Smokers).

14. z
 Management
 NSAIDs – Diclofenac(1mg/kg) ; Ibuprofen ;
Paracetamol(15mg/kg)

15. z
Root Hypersentivity
 During periodontal therapy, scaling and root planing
removes the outer layer of hyper mineralized dentine
and thus leaves the surface expose to the effect of
hydrodynamic phenomenon.
 Post Operative complications
 Poor Oral Hygiene maintenance.

16. z
Management: -
 Warn patient ahead of time!!!
 Determine magnitude of problem and probable etiology
 Does it interfere with daily activities or hurt only when they bite into a
popsicle!!
 Etiology:
 Toothbrush abrasion
 Periodontitis
 Periodontal treatment
 Use desensitizing agents like sodium fluoride, stannous fluoride,
calcium sodium phosphosilicate bioactive glass (novamin®);
resins, varnishes, toothpastes (occlusion of dentinal tubules);
iontophoresis, lasers and gingival grafts

17. z
Increased Tooth Mobility
 Initial reattachment may be evident in the first 10-14
days after surgery which may be the cause of transient
mobility following
 Which more advanced collage nation and renewal of
the gingival attachment to tooth and bone occurs
which may require 30-45 days or more days.
 After 30- 45 days if mobility persists then the
etiological factor for mobility should be identified and
corrected through occlusal adjustment and finally
splinting should be done to stabilize the teeth.
 Although if the mobility is still progressive then
extraction can be considered as an option.

18. z
Post Operative Bacterimia
 Occurrence of post-surgical bacteraemia depends on amount
of trauma imposed during surgery.
 88% of documention indicates +ve.
 Okel and elliot in their study found staphylococcus albus
coagulase negative as most common pathogens involved in
postoperative bacteremia.
 Mc entegart and porterfield in their study concluded
staphylococcus albus as the most frequently isolated micro-
organism occurring six times whereas psedomonas
aerugenosa, streptococcus viridans, alpha hemolytic
streptococcus occurring more than once and neisseria
catarrhalis, the least isolated, occurring only once in
postoperative infection after periodontal surgery

19. z
Management:-
 Antibiotic prophylaxis before surgery
 Amoxicillin
 Amoxicillin and clindamycin were prescribed most
frequently for infection prophylaxis (71.3% and
23.8% of antibiotic prescriptions, respectively).
 Amoxicillin-clavulanate (3.1%)
 Azithromycin, ciprofloxacin, metronidazole, and
trimethoprim-sulfamethoxazole (each <1%)

20. z
Delayed Wound Healing
 Haemostasis, inflammation, proliferation, and
remodelling.
 Infection which results in dead necrotic tissue which
promotes bacterial growth – most common cause.
 Wound dehiscence (un-approximated flap margins),
hematoma, stitch abscess, foreign substances (like
calculus, tooth fragments, periodontal pack), allergic
reactions to graft material, suture material,
periodontal pack, tight closure via suturing.

21. z
 Management:-
 debridement and irrigation
 antibiotics and analgesics

22. z
Trismus
 Trismus is an inability to open the mouth.
 Trismus after periodontal surgery can
occur due to trauma, infection, infection of
masticatory space, inaccurate positioning
of needle.
 To manage - heat therapy, soft diet and
muscle relaxants can be used.
 If the pain is intense then analgesics can
be given.
 If required, diazepam (2.5–5 mg three
times daily) and other benzodiazepines
may be given for muscle relaxation.

23. z
Taste change
 Taste change could be described in the terms of -
 Dysgeusia: disgusting oral taste or altered taste
sensation
 Hypogeusia: reduction in all 4 taste modalities i.e.
sweet, salty, sour and bitter
 Ageusia: no taste sensation is perceived
 Phantogeusia: spontaneous, continuously altered,
often metallic taste which is usually drug related.

24. z
 Can be due to any infection, trauma to any nerve,
invasive procedures, idiopathic or due to any
surgery requiring insertion of a periosteal elevator,
sectioning of tooth, lingual flaps etc.
 Matsuo and yamamoto in their study showed a
significant association between saliva and taste.
Thus, low salivary flow may also alter taste, which
require the use of a sialogogue. (Pilocarpine -
30mg/day)

25. z
 Management
 Administration of zinc (gluconate or sulfate) as it
plays an important role in the regeneration of taste
bud cells.

26. z
Bruising
 Bruising is defined as an injury to underlying tissues
or bone in which the skin is not broken, often
characterized by ruptured blood vessels and
discolorations. Also corners of mouth may become
dry and cracked .
 To prevent further injury or irritation there should be
application of petroleum jelly (Vaseline) or
ointment.

27. z
Local Anesthetic Related
 Toxicity
 Syncope
 Allergy
 Trismus
 paraesthesia

28. z
Local anaesthetic toxicity
 Due to systemic absorption of an excessive amount of the
drug.
 Local anaesthetics block conduction in many tissues in
addition to the peripheral nerve, resulting in toxicity if sufficient
amounts of the anaesthetic reach these other tissues, such as
the heart or brain.
 Signs and symptoms - loss of consciousness, talkativeness,
and agitation, along with increased heart rate, blood pressure,
and respiratory rate.
 Management:- Adequate oxygen supply should be ensured,
cardiovascular status should be assessed throughout and
medical assistance should be provided.

29. z
 Syncope
 most often occurs when the blood pressure is too low (hypotension)
and the heart doesn't pump a normal supply of oxygen to the brain.
 Characterized by pallor, cold, sweaty, dizzy, nausea, loss of
consciousness, dilated pupils.
 Management: - placing the patient in supine position with slight head
down or elevate the legs (to increase cerebral circulation).
 To regain consciousness aromatic ammonia ampoules can be
administered.
 If not recovered maintain airway, check pulse (if absent, indicates
cardiac arrest), and start CPR immediately.
 four sugar lumps may be given orally or intravenous 20 ml of 20-50%
sterile glucose in case of hypoglycaemia.

30. z
 Local Anesthetic Allergy
 Ag - Ab reaction
 Onset, intensity, and severity of symptoms vary
according to method of overdose
 intravascular injections produce rapid onset/ high
intensity symptoms of short duration
 overdose produces a slow onset of symptoms of
gradually increasing severity with a long duration
 rapid absorption, slow biotransformation or elimination
are other methods of overdose.

31. z
 CVS Effects:
 bradycardia, reduced contractility, hypotension, and
eventually circulatory collapse
 CNS Effects:
 initial effects include anxiety, agitation, dizziness,
tremor, tonic/clonic convulsions
 increasing dose may lead to progressive CNS
depression and death from respiratory depression

32. z
 Prevention is best form of management
 Know the drugs you administer
 Always aspirate
 Injections should be given slowly (60 sec for 1.8ml)
 Medical history
 Slow biotransformation and elimination
 Administration of anti-histaminic (benadryl 20 - 40 mg
IV or IM.), Epinephrine 1:1000 concentration 0.3 mg
SC. Or IM. Bronchodilator via inhaler, corticosteroid
100mg IV. Hydrocortisone hemisuccinate

33. z
 Paraesthesia
 Patient reports feeling numb (“frozen”) many hours or days after a local
anaesthetic injection.
 Trauma to the nerve is the most common cause of this.
 In an audit of 741 mandibular third molar extractions, bataineh found
postoperative lingual nerve anaesthesia in 2.6%; inferior alveolar nerve
paraesthesia was 3.9%, developing in 9.8% of patients younger than 20
years of age. Also, a significant correlation was noted between the
incidence of paraesthesia and the experience of the operator.
 It could be transient occurring for hours, days, or months. Discomfort to
patient can be minimised by the use of medications which include the
immunosuppressant prednisone, intravenous gamma globulin (IVIG),
anticonvulsants such as gabapentin or gabitril and antiviral medication,
depending on the underlying cause

34. z
 Hematoma
 Can occur due to injury of the blood vessel by penetration of
needle to far distally during posterior superior alveolar nerve block.
 Hematoma may or may not result in the formation of puncture of
vein by needle but perforation of artery subsequently result in
hematoma which rapidly increases in size until the treatment is
instituted, due to significantly greater blood pressure within the
artery.
 Emergency management begins by gently cleaning the mouth and
locating the source of bleeding and the application of cold
compress, pressure packs, or styptics.
 Tranexamic acid -500 mg in 5 ml by slow iv injection is the drug of
choice.

35. z
Nerve Injuries
 Usually lingual or mental nerve
 Mucoperiosteal flaps are rarely elevated to level of
mental nerve
 Atrophy of mandibular ridge should be taken into
account
 The mental nerve can be visualized and isolated if
necessary
 Lingual nerve injuries are rare with proper surgical
technique and good judgement

36. z
Flap related
 Flap related complications occur most commonly
due to improper incisions - inappropriate visibility
and access of operative area or could cause
overexposure of bone leading to bone resorption
 Improper debridement which may be considered as
crucial factor in the success of periodontal therapy
 Improper suturing which affects the flap
approximation and can lead to reoccurrence of
disease.

37. z
Graft related
 Loosened sutures could lead to displacement of grafts
or contamination of graft.
 Inadequate size of the graft
 Improper root preparation for graft may lead to failure
of graft.
 Allergic reaction to the grafts are rare but can occur in
a hypersensitive patient.
 Commonest failure associated with root coverage
procedures is recipient bed is too small to provide
adequate blood supply.

38. z
Guided tissue regeneration (GTR)
related
 Failures in GTR procedures can result in swelling
which is most commonly associated with pain,
sloughing which can be attributed to a decrease in the
vascular supply to the flap in the early stages of
healing, membrane exposure.
 Membrane exposures is the major complication
associated with gtr technique with a prevalence in the
range of 50 to 100%.
 Cortellini et al., 1990; selvig et al., 1992 reported that
the prevalence of membrane exposure can be highly
reduced with the use of access flaps, specifically
designed to preserve the interdental tissues (modified
papilla preservation technique).

39. z
Suture related
 Suture breakage which results in inappropriate flap
approximation.
 Loose sutures could lead to exposure of gtr membrane or
graft displacement or if they are too tight then it leads to
devitalisation of tissue.
 Type of suture should be chosen carefully as monofilament
sutures are considered more sterile than the braided suture
because of the “wicking effect” of braided sutures that pulls
the bacteria & fluid into the wound site.
 All of these problems could be avoided by choosing the
correct type of suture material placed through proper
technique.

40. z
Periodontal pack related
 Most commonly encountered complications of
periodontal pack are allergy associated with
eugenol based packs.
 Baer and Wertheimer (1961) in their studies
showed that periodontal dressings can cause
greater inflammatory infiltration on the bone and the
inflammatory reaction is greater when the dressing
is directly placed on the bone compared with the
time when it is placed on the periosteum.

41. z